Doctors steer sick patients away from capitated HMOs

Quality concerns drive inadvertent 'cherry picking'

Many doctors unwittingly are helping managed care plans cherry pick healthier patients, while sicker patients are being steered toward safety-net providers, according to a new study.

In a national survey of 787 physicians, 40 percent reported encouraging patients who are sicker or who have more complex illnesses to avoid capitated managed care plans, in which doctors receive a flat monthly rate per patient. At the same time, 23 percent reported encouraging healthier patients to join such plans, finds the study published in the January issue of the Journal of General Internal Medicine.

Although the data dont clearly identify whether it is cost or quality considerations alone that motivate them to make such recommendations, the study shows that physicians are contributing to risk selection among capitated managed care plans, raising legal, ethical and policy issues, according to author Matthew K. Wynia, M.D., M.P.H., of the American Medical Associations Institute for Ethics.

On the one hand, medical leaders have suggested that physicians ought to help their patients make [health plan] selections, because assisting patients in this way is an important form of physician advocacy, the authors note.

Unfortunately, this study shows that even well-intentioned physician advice may foster risk selection, say Wynia and colleagues. Risk selection undermines insurance pools by causing disproportionate enrollment of less costly patients into certain health plans. This is expensive for some payers, who overcompensate health plans with healthier-than-expected enrollees and financially risky for providers who do not or cannot risk-select, such as safety net providers.

Physicians also were asked whether they felt capitated payment plans undermined their ability to offer a quality of care equal to that of other types of managed care reimbursement. One-third of the surveyed

Contact: Ross Fraser
Center for the Advancement of Health

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